Custom-Made E-Vita Graft for Frozen Elephant Trunk With Arch-First Technique Luca Bertoglio, MD, Alessandro Castiglioni, MD, Alessandro Grandi, MD, Tommaso.

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Custom-Made E-Vita Graft for Frozen Elephant Trunk With Arch-First Technique Luca Bertoglio, MD, Alessandro Castiglioni, MD, Alessandro Grandi, MD, Tommaso Cambiaghi, MD, Alessandro Verzini, MD, Roberto Chiesa, MD The Annals of Thoracic Surgery Volume 104, Issue 6, Pages e467-e469 (December 2017) DOI: 10.1016/j.athoracsur.2017.07.022 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Technical sketch of the custom-made E-Vita graft (JOTEC GmbH, Hechingen, Germany). The stent graft is identical to a standard E-Vita Open Plus device (32 mm in diameter and 13 cm long). The surgical graft has been modified by adding 2 branches. The first branch (reperfusion branch) is 10 mm in diameter, at 15 mm from the sewing collar, and it originates with a 90° angle from the main dacron graft. The second branch (debranching branch) is 14 mm in diameter, at 40 mm from the sewing collar (30 mm from the perfusion branch), and it originates with a 60° angle from the main dacron graft. The debranching branch is rotated 90° counterclockwise from the perfusion branch. (B) The custom-made E-vita graft is shown fully deployed with the surgical graft already retrieved and pulled back. (C) The orientation of the perfusion branch is marked with a black line on the standard delivery system of the device. The Annals of Thoracic Surgery 2017 104, e467-e469DOI: (10.1016/j.athoracsur.2017.07.022) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Intraoperative photographs illustrate the main steps of the procedure. (A) The arch-first technique is performed with a Y debranching of the innominate and left common carotid artery using a presewn trifurcated 8- to 12-mm dacron Hemashield Three Branch Graft (Maquet Cardiovascular, LLC, Wayne, NJ) while the patient is cooled to 32°C. The debranching is performed during bilateral axillary perfusion for continuous bihemispheric antegrade cerebral perfusion, and the systemic cardiopulmonary bypass (CPB) is continued through the extra ascending arterial cannula (arrow) during the debranching. (B) The ascending tube is cross-clamped proximally to the ascending cannula (arrow), and selective anterograde cardioplegia is administered. After the ascending graft is opened, the proximal pseudoaneurysm is evident with graft disconnection from the aortic root. The ascending aorta is then replaced with a 24-mm dacron tube graft (Vascutek Terumo, Wädenswil, Switzerland). (C) The distal aortic perfusion is stopped once the core temperature reaches 28°C, whereas bilateral axillary perfusion is continued through the entire CPB time. The aortic arch is opened at the level of the innominate artery origin (zone 0), and the custom-made E-Vita graft (JOTEC GmbH, Hechingen, Germany) is inserted (arrow) over a stiff guidewire (transesophageal echocardiography intraoperative check) placed in the true lumen through a percutaneous femoral access. (D) The distal frozen elephant trunk anastomosis is performed at the level of origin of the innominate artery (zone 0) using the sewing collar, and then, the surgical graft portion of the device is retrieved and pulled back (arrow). (E) The graft is cross-clamped between the branches, and the perfusion branch is cannulated with a 22F arterial cannula (arrow), allowing distal systemic reperfusion and rewarming of the patient. The E-Vita graft is anastomosed to the ascending graft. Then, after standard maneuvers to remove air, the clamp is moved to the debranching side branch. (F) Finally, the debranching trifurcated graft is reattached to the remaining side branch and its remaining third branch is used for completion of air removal. At 32°C, sinus heart rhythm is recovered spontaneously, CPB is stopped, and the procedure is completed. The Annals of Thoracic Surgery 2017 104, e467-e469DOI: (10.1016/j.athoracsur.2017.07.022) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Computed tomography scan assessment of the case. (A) Preoperative multiplanar reformation (left side) and cross-sectional images (right side) demonstrate a proximal root pseudoaneurysm and a residual chronic dissection. (B) Postoperative volume-rendered image (left side) after the frozen elephant technique procedure shows patency of the Y debranching graft and of the left carotid-to-subclavian bypass and thrombosis of the thoracic false lumen (right side). The Annals of Thoracic Surgery 2017 104, e467-e469DOI: (10.1016/j.athoracsur.2017.07.022) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions